CMISP Out Patient Hospital Emergency Appeal


FILING THE APPEAL:
If your out-patient medical service has been denied by the CMISP Medical Director because your medical condition did not meet the CMISP definition of "emergency", you have the right to appeal that decision. REMINDER: To be considered an emergency, your condition, at the time of the out-patient service at the hospital emergency department, had to require immediate diagnosis and treatment, which, if not immediately diagnosed and treated, could have led to serious physical disability or death. If you choose to appeal the service denial, you must request a review of that decision, in writing, within TEN (10) WORKING DAYS of the date of the denial letter from Medical Case Management. You must state that you want to appeal the denial decision and tell why you are dissatisfied. The address is as follows:

CMISP Medical Case Management
9616 Micron Avenue, Suite 670
Sacramento, California 95827
Attention: Appeals

MEDICAL INFORMATION:
You are encouraged to submit additional medical information to substantiate whether you met the criteria for out-patient emergency services. If getting the medical information will require more than the ten (10) working days allowed, you must request a time extension at the time you file the appeal (within ten working days of the denial notification letter). You may request an extension of up to 30 additional calendar days. You are responsible for submitting the additional medical information within the time limit. Your appeal will not be reviewed until the requested time extension has expired.

LATE FILING:
If you do not file an appeal request within the above time period, the appeal will be denied unless it is found that good cause prevented your making a timely request. You must submit verification that the good cause (such as serious illness, hospitalization, incarceration, or similar reasons) prevented a timely administrative appeal request from being made.

REVIEW PROCESS:
Upon receipt of the appeal review request, and once any additional medical information has been received or the time extension has expired (whichever happens first) an appeal physician reviewer will review all of the available medical information to determine whether the condition treated at the hospital emergency department met the CMISP definition of emergency.

APPROVAL:
If the determination is to approve the appealed out-patient emergency department service, the denial is reversed and the service will be authorized by CMISP Medical Case Management. Both you and the hospital will be notified of the approved service status.

DENIAL:
If the determination is to deny the appealed out-patient emergency department service, you will be advised by Medical Case Management with a justification for the denial. If you are dissatisfied with the action taken, refer to the Out-Patient Hospital Emergency Appeal Process-Second Level Appeal.


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